India's Sanitation for All: How to Make It Happen

Series India’s Sanitation for All: 18 How to Make it Happen

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For orders, contact Department of External Relations Fax +63 2 636 2648 [email protected] Contents 3

7 India’s Sanitation for All: How to Make It Happen

9 Sanitation in India: How Bad is It?

12 Making Household Sanitation an Investment Priority

15 Finding Optimal Solutions

23 Moving Forward

Acknowledgement 5

The study Sanitation in India: Progress, Differentials, Correlates, and Challenges (2009) was done by Sekhar Bonu and Hun Kim. Jeffrey Bowyer developed the report based on the ﬁndings of the study. Additional inputs and comments were provided by Sekhar Bonu, Anand Chiplunkar, Maria Corazon Ebarvia, Maria Christina Dueñas, Robert Hood, and Ellen Pascua. The following helped in the ﬁnalization of this publication: Keech Hidalgo, Josef Ilumin, and Gino Pascua.

INDIA’S SANITATION FOR ALL How to Make It Happen 7

roviding environmentally-safe sanitation to millions of people is a signiﬁcant challenge, especially in the world’s Psecond most populated country. The task is doubly difﬁcult in a country where the introduction of new technologies can challenge people’s traditions and beliefs.

This discussion paper examines the current state of sanitation services in India in relation to two goals—Goal 7 of the Millennium Development Goals (MDGs), which calls on countries to halve, by 2015, the proportion of people without improved sanitation facilities (from 1990 levels); and India’s more ambitious goal of providing “Sanitation for All” by 2012, established under its Total Sanitation Campaign. ADB Photo Library The sanitation problem is most evident in urban poor and rural communities, and affects women and children in particular India’s Sanitation for All: How to Make It Happen 8 1) trends inaccesstohouseholdsanitationanddrainageIndia. andChallenges—thatlookedat Correlates, Differentials, study—Sanitation inIndia:Progress, recommendations, listedbelow, are basedlargely onarecent AsianDevelopmentBank(ADB) the significantobstaclesinproviding universalsanitationcoverageinIndia.These This paperdiscussessixrecommendations thatcanhelpkeystakeholdersaddress 2) 4) 6) 3) 5) have theabilitytowieldsignificantinfluenceinsector. organizations.and nongovernment Italsoincludesdevelopmentagencieslike ADB,which ministries,stateandlocalgovernments, cause. Thismayincludepeoplewithingovernment sanitation programs inIndia,aswellthosewhomakepoliciesthatadvancethesanitation In makingtheserecommendations, thispapertargets designersandimplementersof reaching lar Successful pro-poor sanitationprograms mustbe scaledup. Investments mustbecustomizedandtargetedtothosemostinneed. service deliverysystems. and scaleduptoservethosewhocannotprovide fortheirownneedsunderexisting Proper planningandsequencing mustbeapplied. the way“from toilettoriver.” economic growth permits. Regardless ofcost,allsystemsshouldaddress sanitation all Innovative partnershipsmustbeforgedtostimulateinvestments. community-fund raising,whichhasmetgreat successamongtheruralpoor. sanitation andinvolvewomenasagentsofchange.Anotherinnovationisthesocialized change atthecommunitylevel.Efforts mustaddress socioculturalattitudestoward improvements isanappr alternative toawiderrangeofthepopulation.Higher alternative Cost-effective optionsmust beexplored. should target groups orlocationslaggingbehindthefurthest. as Community-LedTotal Sanitation(CL Community-based solutionsmustbeadoptedwhere possible. become wastefulandredundant. investment isanissue.Careful planningisrequired toensure thatinvestmentsdonot inadequate sanitationcanbeassistedrightaway. Duetolimitedr than 450millionIndianslivingbelowthepovertyline,onlyafewofpoorwhohave stimulate investmentsfrom aswidearangeofsour partnerships. may require workingwithawiderangeofpartnersthrough innovativepublic–private private sector, organizations nongovernment (NGOs),andconsumersthemselves.This ge numbersofthepoorest ofthepoor. Successfulmodelsmustbereplicated oach thatonecouldconsiderifaffordability ofsanitation TS) hasbeenfoundtobeeffective inpromoting Appropriate lower-cost solutionsoffer asafe ces aspossible,includingthe -cost optionscanbeexplored when Investinginincremental Assistanceisstillnot esources, programs Anapproach known Thekeyisto Withmore SANITATION IN INDIA How Bad is It? 9

he report Asia Water Watch 2015 projected that India will likely achieve its MDG sanitation target in both urban Tand rural areas if they continue expanding access at their 1990–2002 rates. By 2015, the percentage of people in urban areas served by improved sanitation1 is expected to reach 80%, up from 43% in 1990. In rural areas, the projection is 48%, an incredible improvement over the coverage rate of just 1% in 1990.2 In real numbers, that means more Indians will have improved their sanitation situation from 1990 to 2015 than the total number of people currently residing in the United States—quite an achievement. ADB Photo Library Untreated sewage and uncollected solid waste block drainage and pollute waterways 10 India’s Sanitation for All: How to Make It Happen million. the wastewaterproduced daily bythecity’s present inhabitants,nowclosetoamassive14 alone, existingsewersoriginallybuilttoserviceapopulationofonly3millioncannotmanage Delhi, antiquatedseweragesystemssimplycannothandletheincreased load.InNewDelhi more than1millionpeople, includingIndianmegacities,suchasKolkata,Mumbai,andNew leads tooverflowsofrawsewage.Today, withmore than20Indiancitieswithpopulationsof Sewerage systems,iftheyare evenavailable,commonlysuffer from poormaintenance, which regard forenvironmental andhealthconsiderations. toilets, thecontentsofbucket-latrinesandpits,evensewers,are oftenemptiedwithout challenge istoensure safe environmental sanitation.Eveninareas where householdshave in crowded environments are typicallymore seriousandimmediate.Intheseareas, themain The situationinurbanareas isnotascriticalintermsofscale,butthesanitationproblems excreta collection.Over700,000 Indiansstillmaketheirlivingthisway. 13 millionunsanitarybucketlatrines,whichrequire scavengerstoconducthouse-to-house facilities exist,theyare often inadequate.ThesanitationlandscapeinIndiaisstilllittered with of buildingafacilityfordefecationinornearthehousemaynotseemnatural.Andwhere 8 7 6 5 4 3 2 1 Pakistan, andViet Nam—allwithalowergross domestic product percapitathanIndia or evenlower, percapitagross domesticproduct. Bangladesh,Mauritania,Mongolia,Nigeria, improved sanitationremains farlowerinIndiacompared tomanyothercountrieswithsimilar, This isespeciallytrueforIndia’s sanitationsituation.Despiterecent progress, accessto levels ofservice. the resources andpowertoaccomplishthem.Theydo notnecessarilyrepresent acceptable not tobecomplacent.MDGgoalssimplyrepresent achievable levelsifcountriescommit However, whileIndiamaybe“ontrack”inachievingtheMDGsanitationtarget, itisimportant still defecatesintheopen. In ruralareas, thescaleof the problem isparticularlydaunting,as74%oftheruralpopulation and ruralenvironments are affected themost. just afewofthecountriesthatachievedhigheraccesstoimproved sanitationin2006. kind oftoilet. An estimated55%ofallIndians,orcloseto600millionpeople,stilldonothaveaccessany Ibid. andChallenges.ADB.Based Correlates, Differentials, Bonu,SekharandHunKim.May2009. SanitationinIndia:Progress, World DevelopmentIndicators.2006. Asmeasured bypurchasing powerparity(current$). international ADB,UNDP, UNESCAP, andWHO.2006.AsiaWater Watch CountriesinAsiaonTrack 2015:Are toMeetTarget 10ofthe “Improved sanitationfacilities” are definedunderthe MDGs asthosethatensure hygienicseparationofexcreta from human on author’s analysisofthe2005NationalFamily HealthSurvey. Millennium DevelopmentGoals?.Manila. latrine, andbucketlatrines. ventilated improved pitlatrine.Sanitationsolutionsnotconsidered "improved" include:publicorshared latrine,openpit contact. Thisincludesconnectiontoapublicsewer, connectiontoasepticsystem,pour-flush latrine,simplepitand Tigno, Cezar. Water April2008.Country Action:India,Toilet Technology forHumanDignity.ADB. Dueñas, Christina,April2008.CrusadingforHumanandEnvironmentalDignity . www.adb.org/Water/Champions/pathak.asp. 8

5 Amongthosewhomakeupthisshockingtotal,Indiansliveinurbanslums 6 Intheseenvironments, cash incomeisverylowandtheidea 7

4 3

—are Wastewater treatment capacity is also woefully inadequate, as India has neither enough water to flush-out city effluents nor enough money to set up sewage treatment plants. As of 2003, it was estimated that only 30% of India’s wastewater was being treated.9 Much of the rest—amounting to millions of liters each day—find its way into local rivers and streams. According to the country’s 11 Tenth Five-Year Plan, three-fourths of India’s surface water resources are polluted, and 80% of the pollution is due to sewage alone.10

The impacts on human health are signiﬁcant. Unsafe disposal of human excreta facilitates the transmission of oral-fecal diseases, including diarrhea and ADB Photo Library With improved sanitation facilities in place, children do not have to play in dirty areas a range of intestinal worm infections such as hookworm and roundworm.11 Diarrhea accounts for almost one ﬁfth of all deaths (or nearly 535,000 annually) among Indian children under 5 years.12 Also, rampant worm infestation and repeated diarrhea episodes result in widespread childhood malnutrition.13

Moreover, India is losing billions of dollars each year because of poor sanitation. Illnesses are costly to families, and to the economy as a whole in terms of productivity losses and expenditures on medicines, health care, and funerals.14 The economic toll is also apparent in terms of water treatment costs, losses in fisheries production and tourism, and welfare impacts, such as reduced school attendance, inconvenience, wasted time, and lack of privacy and security for women. On the other hand, ecologically sustainable sanitation can have significant economic benefits that accrue from recycling nutrients and using biogas as an energy source.15

9 Wallace, Bruce. 2007. Drawing a curtain on old ways – In India, a villager uses his own strategy in a campaign to encourage the use of toilets instead of the great outdoors. Los Angeles Times. 6 September 2007. http://articles.latimes.com/2007/ sep/06/world/fg-toilet6?pg=1. 10 Nair, Santha Sheela. 2008. SACOSAN and India’s Experience. Presented at Third South Asian Conference on Sanitation, 18–21 November 2008 in New Delhi. 11 PEP (Poverty-Environment Partnership). 2005. Linking poverty reduction and water management. PEP. www.unep.org/ civil_society/GCSF8/pdfs/pep_linking_pov_red.pdf. 12 Boschi-Pinto, C., L. Velebit, and K. Shibuya. 2008. Estimating child mortality due to diarrhoea in developing countries. Bulletin of the World Health Organization, 86: 710-717. www.who.int/bulletin/volumes/86/9/07-050054/en/index.html. 13 Indian Institute of Population Sciences. 2007. National Family Health Survey, III. Mumbai. 14 UN-Water. 2008. Tackling a global crisis: International Year of Sanitation 2008. http://esa.un.org/iys/docs/IYS_ﬂagship_web_ small.pdf. 15 ADB, UNDP, UNESCAP, and WHO, op cit. Sanitation in India: How Bad is It? Sanitation in India: 12 India’s Sanitation for All: How to Make It Happen

ADB Photo Library T resources. and hasbackedupthiscommitmentwithincreased levelof the importanceofimproving sanitationatthehouseholdlevel ofIndiaclearlyunderstands the nationallevel.TheGovernment and onecanargue thatithasalready happened,atleaston Women insanitation—buildingtheirown toilets an InvestmentPriority Making HouseholdSanitation agenda inIndia.Thismayseemanobviousconclusion, household sanitationonthetopofdevelopment he firstvalidactionforstakeholdersmustbetoput Through its Total Sanitation Campaign (TSC), Table 1: Shift in thinking about sanitation the Government has sanctioned projects in all of India’s rural districts, building about Old way of thinking New way of thinking 57 million individual household sanitary Sanitation is high cost and Sanitation is affordable when the right latrines (IHHLs).16 While this achievement unaffordable. technology is installed, reasonable still falls short of the estimated 119 million financing is offered, and a creative mix units needed to meet the Government’s goal of providers shares the cost. of eradicating open defecation by 2012, The poor have more important Households—even poor ones— investments in rural sanitation continue to needs than sanitation, and are willing to pay for sanitation increase—from around $90 million in 2004 they cannot afford it. 13 to $280 million in 2008.17 For urban areas, the Government has also made substantial Sanitation is not a high priority Making sanitation a priority commitments. In addition to state-allocated for governments. delivers big economic, health, and funds, the most recent five-year plan allocates environmental benefits. 7,816 rupees cr.18 ($1.6 billion) for urban High-cost technology is needed There are already innovative and sanitation projects.19 to make sanitation work. low-cost—even waterless— technologies that can be used for Despite these current efforts, many more wastewater management. billions of dollars of public resources will still Governments and utilities do not have Financial viability can go with public need to be deployed effectively in tandem with access to finance. affordability, and full cost recovery private resources for comprehensive sanitation is feasible, provided the sanitation systems—all the way “from toilet to river.” Part services are customer-oriented and of the problem is that investment programs worth paying for. still tend to focus solely on constructing Source: Dignity, Disease, and Dollars: Asia’s Urgent Sanitation Challenge. Why Invest in Sanitation. ADB. conventional collection and treatment systems that do not always benefit the poor. While costly infrastructure projects continue to be approved, lack of resources has long provided a pretext for relative inaction among underserved urban and rural populations in India.

It is time for a change. Project designs must shift away from top–down and supply-driven approaches and support sanitation models that are more demand-driven, people-centered, and community-led. Toilets are an important but often-overlooked component—these must conﬁne feces until they are composted and safe, or enable them to be ﬂushed away into a sewer.20 Moreover, comprehensive efforts should include environmental cleanliness; hand- washing; and garbage and wastewater collection, treatment, and disposal.

To affect this change, relevant stakeholders, especially politicians in state and local governments, must “get their hands dirty” by engaging in sanitation projects and making resources available, particularly for the poor and unserved sectors. The motivation for action is there, as it is clear that improved sanitation is vital for good health and social development, a good economic investment, and improves the environment. However, reaping the beneﬁts of improved sanitation will require decision makers at all levels to shift their way of thinking about sanitation and recognize that universal coverage is affordable and achievable (Table 1).

16 Bhaskar, T.M. Vijay, Joint Secretary, India Department of Drinking Water Supply. 2009. Sustaining the Sanitation Revolution: India Country Sanitation Status. Presented at ADB-DMC Sanitation Dialogue. Manila. 3-5 March. 17 Nair, op cit. 18 A crore, often abbreviated cr, is a unit in the Indian numbering system equal to ten million (10,000,000; 107). It is widely used in Bangladesh, India, Maldives, Nepal, and Pakistan. 19 Bhaskar, op cit. 20 UN-Water, op cit. Making Household Sanitation an Investment Priority 14 India’s Sanitation for All: How to Make It Happen

ADB Photo Library expenditures ofthesameorder ofmagnitudewillalso berequired. latrines—a fairlymodesttarget. the MDGtarget for“improved sanitation,”whichcanbemetbyconstructingsimplepit an inexpensive energy source Provision oftoiletsconnectedtobiogasdigesters hashelpedcommunitiesgainaccesstosanitationand 22 21 investments of$38billionupto2017,theendIndia’s 12 According toaWorld Bankreport, simplymeetingtheMDGtarget wouldrequire total would require about$2.2billionforurbanareas and$1.65billionforruralareas. Makino, Midori.2006.India–Water SupplyandSanitation:BridgingtheGapbetweenInfrastructure andService.World At $1=Rs42.5.Assumptionsare unknown,butthehigherestimateforurbanareas suggeststhattheprescribed optionfor WorldBank_BG_Urban_20Feb06.pdf. Bank. January. http://siteresources.worldbank.org/INDIAEXTN/Resources/Reports-Publications/366387-140691677823/ urban areas ismore advancedthanthatforruralareas (e.g.,septictankwithasoakpit). th Five-Year Plan.Annually, that 22 Andthisisjusttosatisfy 21 Recurrent Finding Optimal Solutions 15

his section provides a number of recommendations for policy makers and project designers and implementers in Tapproaching India’s considerable sanitation challenges. The focus here is on household sanitation, including the safe disposal of human excreta, as measured by household ownership of a sanitary latrine,23 and household access to drainage facilities.24

Figure 1: Wealth-based differentials in the A. Successful pro-poor sanitation programs must be progress of households with toilets (%) scaled up

Poorest Qunitile 2nd Poorest Middle As clearly shown over the past decade in India, increased 2nd Richest Richest Quintile 100 98 investment is only part of the challenge—it does not guarantee 94 94 that the poorest will be reached. With a handful of sanitation 90 Source: National Family Health Surveys of India, 1992-1993; 1998-1999; and 2005-2006 projects successfully implemented for India’s urban and rural 80 poor, the challenge now is to scale up models to a level where 74 70 they make a real and lasting impact at the national level.

60 57 Despite the signiﬁcant efforts of the government and many 50 NGOs to target them over the past two decades, poor

40 households are still lagging far behind. The ADB study shows 38 34 that sanitation services for the lowest income group improved 30 the least between 1992–93 and 2005–06. Instead, much of the Percentage of households with toilets 22 20 advances have been enjoyed by the middle and upper-middle 14 15 classes (Figure 1). Thus, governments and the international 10 9 4 5 community must now fully focus their attention on those 2 0 1 sections of society that cannot provide for their own needs 1992-93 1998-99 2005-06 Year under existing service delivery systems. Source: National Family Health Surveys of India, 1992–1993, 1998–1999, 2005–2006.

23 Based on data from past three National Family Health Surveys: April 1992– September 1993 (NFHS-1), November1998–December 1999 (NFHS-2), and November 2005–August 2006 (NFHS-3). 24 Based on data from 60th round of the National Sample Survey (January–June 2004), which sampled 73,868 households containing 385,055 individuals. 16 India’s Sanitation for All: How to Make It Happen s by takingthesefactorsintoconsideration. insights onhowsocioculturalfactorsmaybehinderingprogress, andcustomizeinterventions below, canhelpdesignersofsanitationprograms target certainpopulationgroups, gain resistance toadoptinghouseholdsanitationfacilitiesthanothers.Theresults, summarized The ADBstudyrevealed thatcertainareas andpopulation groups inIndiahavegreater residence) orbyshapingtheculturalattitudestowards usingpublicorhouseholdfacilities. drainage, eitherbyinfluencingdifferentials inpublicpolicy (e.g.,stateofresidence, urban/rural (e.g., residence, caste,educationstatus,religion) affect accesstohouseholdsanitationand Empirically-driven research isvitalinthiseffort. Socioeconomicbackground characteristics need. investments andmakepublicpoliciesexpenditures more efficienttotarget thosemostin of thepoorcanbeassistedbyIndia’s target of2012.Thus,decisionmakersmustprioritize 29 28 27 26 25 povertylineof$1.25perday.population) stilllivebelowtheinternational According tonewWorld Bankestimates,some456 millionIndians(orabout42%ofthe B. Investmentsmustbecustomizedandtargetedtothosemostinneed s s SCs andSTs are populationgroupings thatare explicitlyrecognized bythe ConstitutionofIndia,andotherwiseknownas Census ofIndia,2001. In allofthesestates,atleast85%households haveaccesstoatoiletfacilityandatleast65%someform In allofthesestates,lessthan60%householdshaveaccesstoatoiletfacilityand50%some Chen, Shaohua,andMartinRavallion.2008.TheDevelopingWorld ThanWe isPoorer Thought,ButNoLessSuccessfulin the 2001census. untouchables. SCs/STs togethercompriseover 24%ofIndia’s population,withSCsatover16%andSTs over8%,asper of drainage. form ofdrainage. the FightAgainstPoverty.World Bank.PolicyResearch Working Paper4703.Washington, D.C.August. south. Himachal Pradesh,Gujarat,andRajasthaninthenorthwest;Tamil Naduinthe Bengal. Otherstateswithrelatively lowlevelsofsanitationanddrainageserviceinclude including AndhraPradesh,Chhattisgarh,Jharkland,MhadyaOrissa,andWest and drainagetendtobetherelatively poorer statesclusteredIndia, incentralandeastern State-level differentials. include someofthemostdisadvantagedgroups inIndia, Caste-based differentials. Religion-based differentials. barrier toaddress sanitation challenges. a lowlevelofeconomicdevelopmentdoesnotnecessarilypresent aninsurmountable Hindus accountfor80.5%ofthetotalpopulationinIndia. above, eightofthemhaveHindupopulationsexceeding88%theirtotalpopulations. 74% respectively. Itisalsoworthnotingthat,ofthetenpoorperformingstateslisted Muslim households(60%).ChristianandSikhfare muchbetter, at70%and households havethelowestpercentage ofhouseholdswithatoilet(41%),followedby better, withaccessat32%fortoiletsand46%drainage. with dispersedhamletsandremote ruralandforest areas. SChouseholdsfare slightly is likelyduetoahighdegree ofinequalityinaccesstobasicdrainagefacilitiesassociated 2005–06. Moreover, only23%ofSThouseholdshaveaccesstoanyformdrainage.This sanitation anddrainage.SThouseholdshavethelowestownership oftoilets—only18%in are locatedinthenortheast. 26 Conversely, manyofthestateswithhighestcoveragetoiletsanddrainage Statesthathavelowcoverageforbothhouseholdsanitation Scheduled castes(SCs)andscheduledtribes (STs), which 27 Thesestatesare alsorelatively poor, whichsuggeststhat Religion-baseddifferentials are alsosignificant.Hindu 29 bothsuffer from poorhousehold 28

25 Realistically, notall s Education-based differentials. Education-based differentials in households lacking toilets are large and continue to persist over the last decade. Households whose heads of household are illiterate have the least access to toilets—77% in 2005–06. Unlike wealth- and caste-based differentials, progress in access to toilets by various household education categories appears uniform over the last decade.

These results might suggest certain directions for sanitation programs. For instance, in prioritizing investments, programs might consider targeting those states that are lagging the furthest behind, such as Chattisgarh and Orissa. To be successful, it is also clear from the results that programs must take into account cultural factors and high levels of illiteracy. 17

C. Cost-effective options must be explored, guided by proper planning

The ADB study also revealed that those states that have implemented affordable and sustainable sanitation options have higher rates of coverage for household sanitation and drainage.

Figure 2 compares Assam and Kerala Figure 2: Access to different types of toilets (2005–06) states with Maharashtra and Gujarat, two 100% of the richest states in India (in terms of gross domestic product per capita). In 80% both Maharashtra and Gujarat, nearly 30% Flush-piped sewer of the households have access to a ﬂush system toilet with a piped sewer system, but both 60% Flush to septic tank states also have a high percentage of the Flush to pit latrine population with no toilets. Conversely, 40% both Assam and Kerala use lower-cost Pit and others solutions, such as pit latrines, to achieve 20% No toilet much higher rates of coverage. Thus, by adopting low-cost solutions Assam and 0% Kerala managed to increase toilet coverage Maharashtra Gujarat Assam Kerala despite economic hurdles. Source: National Family Health Surveys of India, 2005–2006.

Figure 3 offers another comparison involving Maharashtra and Gujarat. These two states lead India in the percentage Figure 3: Access to different types of drainage (2004) of households served by underground 100% drainage systems. And yet, these states also leave a much higher percentage 80% of their populations without any form of Underground drainage compared to those states that Covered Pucca have pursued less advanced (but cheaper) 60% Open Pucca options, such as open puccas (channels with concrete lining drainage systems). 40% Open Kuccha

In the three other states listed—Haryana, No drainage

Punjab, and Uttar Pradesh—more than 20% 70% of the households are served by some form of drainage system. 0% Maharashtra Gujarat Punjab Haryana Uttar Pradesh These findings suggest that sanitation programs in India should consider pursuing Source: National Sample Survey of India, 60th Round (January to June 2004). National Sample Survey Organization in India. Note: Open kuccha=mud drainage with no concrete lining; pucca=channels with concrete lining drainage systems. Finding Optimal Solutions 18 India’s Sanitation for All: How to Make It Happen sanitary facilities,eveniftheyhavemotivationandcapacity. result, slumcommunitiesdo nothavetenantrightsandare “notallowed”toinvestinproper urban population.Theyare oftenomittedfrom demographicstatisticsandtownplans.Asa mayalsodisregardgovernments squattersettlements,whichabsorbmuchofIndia’s growing still believethatsubstandard interventionsare allthat ispossible. view sanitationinvestmentsastoocostlyandnotsustainableorreplicable. Worse, some To mustchangetheircurrent accomplishthis,localgovernments mindset.Manystill options. communities canthengraduallyimprove thequalityofsanitationserviceswithhigher-cost the greater thebenefitsforpeopleandenvironment. Aseconomicgrowth permits, phased-development approach isideal.Thefurtheronegoesupthe“sanitationladder,” Given thatmostcommunitieshavelimitedresources, theconventionalwisdomisthata cleanliness ofthesefacilities(seeBox1). safe sanitationoptionforpoorcommunities.Thekeyisensuring proper managementand as animprovement andthewidelyheldperception thatpublicfacilitiescannotprovide a problems, despitethefactthatMDGsanitationtarget doesnotcountshared facilities Public facilitiescanalsobepartofahygienicandaffordable solutiontoIndia’s sanitation front-end coststendtobemore expensivethanotheroptionsdowntheladder. lack ofdependenceonwater. However, skilledlaborisrequired fortheconstructionand a soilconditioner, reduced useofchemical fertilizers,reduced pollutionofgroundwater, and or manure. There are manyadvantagesofgoingthisroute, includingreuse ofthecompostas composting toilets,whichusemicroorganisms tobreak downthewasteintoorganic compost programs thattarget thepoorinIndiashouldconsiderjumpinganumber ofrungsdirectly to Given thesechallengesatthelowerendofladder, thispapersuggeststhatsanitation ongoing costs. and transfertoaseptagetreatment facility. Theserequirements greatly addtofront-end and to carryawaythewastewater, andservicesforeventuallydealingwiththecollectionofsludge ample watersupplyisreadily available,aswellproperly-constructed septictanks,drainage regularly, which isadifficultprospect incrowded areas. Pour-flush latrinesrequire thatan cleanliness are oftenatodds. Thesimplestoption—apitlatrine—mustbemovedoremptied This iswhere sanitationbecomes particularlychallenging,asaffordability andenvironmental pathogens andpollutantscannotbeallowedtoenternearbywatersources, includingaquifers. these systemsmustalsoaddress sanitationalltheway“from toilettoriver,” meaningthat confined untiltheyare composted andsafe.Regardless ofthetoilettechnologyselected, ensure hygienicseparation ofexcreta from humancontact,whichmeansfeces must be The firststepistoprovide basic sanitation—ortoilets.Asmentionedearlier, thesemust 32 31 30 cheaper formsofsewerage,canbetooexpensiveandimpractical. fiscal constraints.Intheworstslums,eventechnologicallyscaled-downapproaches, like appropriate lower-cost solutionsthatcatertoawiderangeofthepopulationwithincurrent Nair, opcit. Dueñas, Christina.2005.Water Champion:JoeMadiath-Championing100%SanitationCoverage inRuralCommunities UN-Water, opcit. India. November. www.adb.org/Water/Champions/madiath.asp. 32

31 Inurbanareas, local 30

19 M. Ebarvia There are technologies, such as engineered reed beds and duckweed ponds, that provide low-cost wastewater treatment and reuse solutions

Regardless of the technology selected, making sanitation improvements in any community requires careful planning and concerted investment efforts between households and governments. Lacking proper coordination, some investments can become very wasteful and redundant. For instance, the disposal of contaminated wastewater in densely populated areas is both expensive and technically challenging, while the prospects for charging for this service are limited. Thus, if water services are introduced in an area without a proper drainage and sewerage system, there will be no way to take away the volumes of dirtied water.

For up-and-coming communities, it may be possible to leapfrog lower-cost options by connecting toilets to a sewerage or a combined sewer-drainage system with wastewater treatment facilities. In those cases, user fees for capital plus operations and maintenance costs must be built into the project cost and approval process so that the wealthy pay for services that cannot be provided universally otherwise.

The choice of on-site wastewater treatment systems versus off-site systems must consider population densities and investment capacities.33 Reuse of treated wastewater (e.g., water supply for ﬂushing toilets, watering plants/gardens, and irrigation) should also be considered.

Finally, stakeholders must remember that the supply of latrines and toilets by themselves will not improve health. All members of the community must regularly use them and also wash their hands after use to break the fecal–oral cycle in the spread of disease.

33 Bonu, Sekhar and Hun Kim. 2009. op cit. Finding Optimal Solutions 20 India’s Sanitation for All: How to Make It Happen 38 37 36 35 34 involved. lack ofawareness abouttheimportanceofsanitation,andmisconceptionscosts preparation offood).Acombinationfactorstrapsthemintothispractice,includingtradition, and tryusingindoorfacilities,alongwithotherhygienicpractices(e.g.,washingofhands,safe In manypoorslumsandruralvillages,itisdifficulttoconvincepeoplestopopendefecation toprovidesupply andsanitationneeds,withoutwaitingforthegovernment everything. totakechargeshift intheirculturalpracticeofdisposinghumanwasteandlearn oftheirwater open defecationisthenorm,suchasinmanylarge Hindistates,peoplemustmakearadical facilities orfunding,butonculturalattitudesandbehaviortowards hygiene.Intheareas where The studyresults alsosuggestthatIndia’s sanitationproblems lienotjustonthelackof D. Community-basedsolutionsare themosteffective in forminghabitsoftheirchildren. have, byfar, the mostimportantinfluenceindetermininghouseholdhygienepracticesand women, astheyare theworst sufferers duetonon-availabilityofthesefacilities. Women In thiseffort, itisimportant tounderstandthatmuchofthedemandforlatrinescomesfrom illiterate, abouttheneedtouselatrinesandimportanceofhygiene. household toilet.Inmanycases,thiswillrequire educatingSCsandSTs, manyofwhomare practices. Theseefforts must includeaddressing socioculturalattitudestoward owning a organizations canacceleratetheprocess ofchangeandhastenthe adoptionofsanitary education, andcommunication(IEC)campaignsinvolvingcommunitiesgrassroots For policymakersandprogram implementers,experiencehasshownthatinformation, 200 ruralvillagesinOrissaacquire goodqualitytoiletsandbathrooms, coupledwithatleast 2). Through itsRuralHealthandEnvironment Program (RHEP),theNGOhashelpedmore than success byGramVikas, anNGOthatworkswiththeruralpoortoimprove sanitation(seeBox One innovationissocializedcommunityfund-raising,whichhas beenimplementedwithgreat defecation havebeenshowntowork. communities. Messagesthatappealtotheneedforprivacyandsocialstigmaofopen often startwithmakinghouse-to-housecontacttoeducateandmotivatewomenintarget planning, implementation,andmonitoring. and thateveryoneinthevillageneedstocontributemakeeffort successful,including they needsanitationfacilities;thatshouldmobilizethemselvestobuildtheirowntoilets; their behaviorisunhygienic.Thisgrassroots approach ofCLTS helps residents recognize that environment, insteadofprescribing therightlatrinemodelsortellingpeopleupfront that Some ofthemore successful efforts focusonempoweringpeopletoanalyzetheirown manage theirsanitationproblems. not themonopolyofengineersandtechnocrats,before theyhavetheconfidencetouseand Tigno, Cezar. Water aDirtyOldHabit.January. 2009.Country Action:Bangladesh-Breaking www.adb.org/Water/Actions/ ADB. 2006.PlanningUrbanSanitation&Wastewater ManagementImprovements. Appendix3:SomeGlobalCaseStudies. WaterDueñas, Christina.2009.Country Action:India-ChangingtheSanitationLandscape.February. www.adb.org/Water/ Ban/Breaking-Dirty-Habit.asp. May. www.adb.org/Water/tools/Planning-US-WSS.asp. Actions/IND/Sanitation-Landscape.asp. Jha, Dr. PK,opcit. Dueñas, Christina.2005,opcit. 34 In addition, communities must learn thattechnologies,evensimpleones,are Inaddition,communitiesmustlearn 36 35 Thus,thesocialmarketingofmanysanitationprograms

38 three taps per household and 24-hour water supply. Box 1: Sulabh International’s Pay-and-Use Approach Most of these villages are tribal and dalit, really the poorest of the poor, which makes their success all Sulabh plays the role of a catalyst and a partner between the ofﬁcial the more incredible.39 agencies and the users for the construction, operation, and maintenance of public sanitation facilities. As part of this arrangement, the cost E. Innovative partnerships must be forged to of construction is met by the local body, while Sulabh agrees to a stimulate investments maintenance guarantee of not less than 30 years.

To help realize higher levels of service coverage The NGO makes this arrangement financially viable through user’s and quality, sanitation programs must stimulate charges—it charges 1 rupee per use of toilet or bath and the use 21 investments from as wide a range of sources as of urinals is free (vulnerable and poor people, such as physically possible, including consumers themselves and the handicapped, aged, and street children, are allowed to use the services private sector. Successful public–private partnership for free). Sulabh has found that cleanliness is the single biggest factor (PPP) models can help overcome the limitations of influencing the extent of service coverage. Thus, its management local governments, which are under tremendous practices include round-the-clock management by caretakers and pressures in view of rapid urbanization and fast- sweepers and continuous availability of power, water, and soap powder. growing slum and low-income populations. Sulabh does not depend on external agencies for finances, relying In the sanitation sector, partnership arrangements instead on internal resources. For those toilet complexes that are not between the public and private agencies, with the self-sustaining (usually those located in slums and less developed involvement of community networks, such as NGOs areas), the maintenance costs are cross-subsidized from the income and CBOs, have proven to be successful.40 In India, generated from toilet complexes in busy and developed areas. If there these private sector partners will mostly be local, is leftover money, they spend it on sanitation-related activities and on since transnationals will not be interested in much welfare programs, such as children’s education and training of women beyond a few major cities. scavengers.

Several Indian NGOs have actually crossed over Box 2: Socialized Community Fund-Raising in Orissa to become formal private operators while retaining their NGO character. For instance, in 1999, the Pune Over the years, the NGO Gram Vikas has pioneered mechanisms that Municipal Corporation (PMC) implemented a citywide ensure building sustainability in water and sanitation, centered on the sanitation program for 500,000 people. Only NGOs Indian state of Orissa. Socialized community fund-raising is one of their were allowed to bid for the project to ensure that the hallmark strategies. Except for the initial social costs, the community community participated in the construction, design, shoulders all the expenses. Villages cofinance projects through a and maintenance of block toilets. PMC remained “corpus fund” of 1,000 rupees, which the community must raise. This a facilitator, and communities handled the major corpus is actually an acid test to see if people can set their differences decisions. The project, implemented within budget apart and work together. and on schedule, was successfully replicated in Mumbai.41 A family’s contribution to the corpus fund is determined by their economic capacity, with the poor giving lesser contributions. The fund is Perhaps the best example of an Indian NGO taking on put in an interest-earning deposit and the interest is used for operations a private sector role is offered by Sulabh International. and management, and for extending support to new families in the The NGO enters into interventions and activities in village. Through the funds, the NGO has been able to leverage additional collaboration with municipalities and other public resources. Gram Vikas has also started using it as collateral to source agencies and earns profits in the process. It reinvests more funds from financing institutions, and have used them to start its profits only into the company, not in the market, village industries so that there is no unemployed person in the village. and subsidizes the exceedingly poor communities Source: V. Srinivas Chary, A. Narender, K. Rajeswara Rao. 2003. Serving the Poor with Sanitation: rd that cannot afford to pay for their toilets.42 The Sulabh Approach. 3 World Water Forum, Osaka, 19 March 2003. PPCPP Session.

39 ADB. 2006. Bringing Water Supply and Sanitation Services to Tribal Villages in Orissa the Gram Vikas Way. April. www.adb.org/water/actions/IND/gram-vikas.asp. 40 V. Srinivas Chary, A. Narender, K. Rajeswara Rao. 2003. Serving the Poor with Sanitation: The Sulabh Approach. 3rd World Water Forum, Osaka, 19 March. PPCPP Session. 41 ADB. 2007. Dignity, Disease, and Dollars: Asia’s Urgent Sanitation Challenge. www.adb.org/water/operations/sanitation/pdf/dignity-disease-dollars.pdf. 42 Dueñas, Christina. 2003. Water Champion: Almud Weitz - Breaking Barriers in Serving the Urban Poor. July. www.adb.org/water/champions/weitz.asp. Finding Optimal Solutions 22 India’s Sanitation for All: How to Make It Happen

ADB Photo Library Pay-and-use toilets: Userfeeshave tobecollectedensure cleanlinessandmaintenance ofthefacilities 43 creates anatmosphere ofcontinuingmistrustratherthancooperationorpartnership. expectations andtheneedtoscaledownrevise targets immediately thereafter, which assessment ofservicesisasaccuratepossible.Thatway, partiescanavoidunrealistic frameworks before entering intocontractsor, attheleast,makesure thatthebaseline They canalsocontinueurging toeitherﬁxtheprocurement governments andregulatory a keyfactorinformulating,implementing,andsustainingsuchpartnerships. and regulation. Thecommitmentofpoliticalleadersandthecooperationpublicagenciesis water utilityproviders andregulators onincorporating pro-poor elementsinfuture contracts In thiseffort, sanitationprograms shouldconsiderincreasing theiradvocacyandtrainingfor that promoters ofsocialreforms gainthetrustof people andcultivatetheirpartnership. agencies.Itisalsoimportant localbodies,NGOs,communities,andinternational governments, promote similarorganizations andPPParrangementsthatinvolveacollaborationof To ensure greater servicecoveragewhileincorporatingsocialreforms, there isaneedto ﬁnancially viable. willing topayforimproved waterandsanitationservicesthatsuchoperationscanbe hasproven(see Box1).Insodoing,SulabhInternational thatpoorslumcommunitiesare 7,500 communitycomplexesithasconstructedtocaterthepoorandlow-incomesections Among itsmanyinnovations,Sulabhhasadoptedapay-and-useapproach tomaintainsome Dueñas, Christina.2003.opcit. 43

Moving Forward 23

his discussion paper has provided a number of recommendations to help future sanitation programs Tforge a new path to provide sanitation for India’s urban and rural poor. It has shown that these programs must involve more than just constructing new facilities for a given number of people. They must also include efforts to build momentum behind sanitation and hygienic behavior by mobilizing consumer demand in different settings.

Sanitation programs must also use a menu of different approaches, such as ﬁnancing at the household level and a range of affordable sanitation options for potential consumers. This may require working with a range of new partners, including public health ofﬁcials, grassroots organizations, and private sector, something that should not be seen as a deterrent.

For ADB, helping India meet this challenge comes at the right time. Recognizing that poverty will never be alleviated without realizing the huge health and economic beneﬁts of improved sanitation, ADB has stepped up its efforts to catalyze investments in the sector.

Already, the share of sanitation projects in ADB’s water lending portfolio has doubled, from an average of 4.5% in 2003–2007 to 8% in 2008–2010. ADB also recently committed 20% of its Water Financing Partnership Facility (WFPF)44 to sanitation ADB Photo Library Substantial ﬁnancial commitments for sanitation projects investments, taking on the more comprehensive “from toilet to in both rural and urban communities have been made river” approach, which highlights not just household sanitation by the Government of India as part of its Total Sanitation but wastewater treatment and environmental sanitation as well. Campaign

44 The aim of the Water Financing Partnership Facility (WFPF) is to access additional ﬁnancial and knowledge resources from development partners to support the implementation of ADB’s Water Financing Program which seeks to double ADB’s investments in the water sector. 24 India’s Sanitation for All: How to Make It Happen

ADB Photo Library Communication, education, and working withthecommunityaspartnerare key aspectstostimulatedemandforsanitation maintained onceaccesstofacilitiesisimproved. OnlythenwillIndiaachieve“sanitationforall.” what investmentstomake,howtheyare organized andpaidfor, andhowservices are runand The wayforward isclear—toprovide people,including thepoor, withincreased choicesover the sanitationmovementinIndia. beginning toshifttoward amore demand-drivenapproach tosanitationthatisconsistentwith Along withgreatly increased fundingandtechnicalsupport commitments,ADBisalso

India’s Sanitation for All: How to Make It Happen

Providing environmentally safe sanitation to millions of people is a significant challenge. The task is doubly difficult in a country where the introduction of new technologies can challenge people’s traditions and beliefs.

This report examines the current state of sanitation services in India and offers six recommendations that can help key stakeholders work toward universal sanitation coverage in India: scaling up pro-poor sanitation programs, customizing investments, exploring cost- effective options, applying proper planning and sequencing, adopting community-based solutions, and forging innovative partnerships.

About the Asian Development Bank

ADB’s vision is an Asia and Pacific region free of poverty. Its mission is to help its developing member countries substantially reduce poverty and improve the quality of life of their people. Despite the region’s many successes, it remains home to two-thirds of the world’s poor: 1.8 billion people who live on less than $2 a day, with 903 million struggling on less than $1.25 a day. ADB is committed to reducing poverty through inclusive economic growth, environmentally sustainable growth, and regional integration. Based in Manila, ADB is owned by 67 members, including 48 from the region. Its main instruments for helping its developing member countries are policy dialogue, loans, equity investments, guarantees, grants, and technical assistance.

For inquiries, please contact [email protected]

Asian Development Bank 6 ADB Avenue, Mandaluyong City 1550 Metro Manila, Philippines www.adb.org/water Publication Stock No. ARM090755 Printed in the Philippines